Implementation of a Pathway for the Treatment of Fever and Neutropenia in Pediatric Patients With Cancer

Abstract

Fever and neutropenia is an oncologic emergency. Time-to-antibiotics (TTA) refers to the amount of time from initial provider evaluation for fever and neutropenia to intravenous antibiotic administration. Research supports that rapid time-to-antibiotics (RTTA) is associated with improved patient outcomes. This quality improvement project evaluated the success of implementing an RTTA pathway in pediatric oncology patients with fever and neutropenia. The setting was an advanced practice nurse-managed pediatric ambulatory infusion center where patients with fever and neutropenia were often evaluated and treated. In order to improve TTA, a multidisciplinary pathway was implemented with a goal of TTA that was less than 60 minutes from initial provider evaluation. Implementation of the RTTA pathway included discussion of shared expectations with the pharmacy and education departments and discussion of shared expectations with the bedside nurses and advanced practice nurses staffing the unit. Additionally, a preliminary lab test was utilized. Success of the implementation was evaluated through 2 measures: TTA and nurses' knowledge of fever and neutropenia and the importance of RTTA. The aims of this project were to improve TTA as well as nurses' knowledge of fever and neutropenia and the importance of RTTA, and both these aims were successfully attained.

The Golden Hour: Sustainability and Clinical Outcomes of Adequate Time to Antibiotic Administration in Children with Cancer and Febrile Neutropenia in Northwestern Mexico

“… 26 Our TTA definition assessed time from the initial provider evaluation to intravenous antibiotic administration; the studies in El Salvador and the Philippines used the time to hospital arrival to calculate their TTA. 16 , 17 However, when compared with a study carried out in an outpatient unit that used the same TTA definition, 32 the median TTA before intervention in our inpatient area (75 minutes) was similar to their findings (79.6 minutes); the reported TTA reduction after the intervention was 48%. We reduced the median TTA by 47% in the inpatient area and 53% in the ambulatory area.…”

An Initiative to Decrease Time to Antibiotics for Patients With Fever and Neutropenia

“…Other projects have employed many different interventions with the goal of delivering antibiotics in less than 60 minutes, including process improvements and implementation of pathways or order sets. 7,[14][15][16][17] Volpe et al employed several unique interventions including the initiation of a "Fast Pass Alert System" to prioritize these high-risk patients. 18 Likewise, Yoshida et al trialed a rapid laboratory test for ANC with good results.…”

Interventions aiming to reduce time to antibiotics (TTA) in patients with fever and neutropenia during chemotherapy for cancer (FN), a systematic review

“…1. Thirty studies were included, thirteen in adult [12,[20][21][22][23][24][25][26][27][28][29][30][31], and seventeen in pediatric patients [16,[32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47], including a total of 1891 and 6820 FN episodes, respectively. Two-third of the studies were undertaken in the USA (n = 20; 67%).…”

“…TTA was measured from triage or arrival at the hospital to first dose of antibiotics in the majority of studies (n = 26; 87%). One study with adult patients started measurement of time at fever detection [30], one study defined TTA as time from initial provider evaluation to intravenous antibiotic administration, [44], and the third study started measurement at ICU admission [32]. In one study, a definition was lacking [36].…”