Neutropenic Fever: One Institution's Quality Improvement Project to Decrease Time From Patient Arrival to Initiation of Antibiotic Therapy

Abstract

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 hospital performance in the treatment of febrile neutropenia

“…Hospitals without such electronic order systems will need to find different methods of analysis and solutions. Indeed, paper order sets have been found to be effective in reducing treatment time [8,13]. In addition, our institution did not have physician trainees involved in the care which alter the processes of patient care and can create (or ameliorate) delays depending upon deployment.…”

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%).…”

Implementation of an Evidence-Based Order Set to Impact Initial Antibiotic Time Intervals in Adult Febrile Neutropenia

“…Failure to inform the physician office or emergency room staff of their neutropenic status may also cause delays in assessment, treatment, and initiation of antibiotic therapy (Cull & Nolan, 2009). Organizational reasons for delays in early initiation of antibiotic therapy include system issues with antibiotic orders, delays in transfer from the emergency department to the inpatient unit, issues with the pharmacy's process for filling medications, or a delay in the administration of the medication by the patient's nurse (Baltic et al, 2002).…”

“…For patients who develop febrile neutropenia, prompt assessment and initiation of treatment with appropriate antibiotic therapy is essential to ensuring positive outcomes. The use of a standardized order set for this population can ensure that patients receive prompt treatment for infection (Baltic et al, 2002;Nirenberg et al, 2006a).…”

“…Patients who develop febrile neutropenia following chemotherapy require hospitalization to receive antibiotic therapy. Delays in initiation of antibiotics can occur at any point in the admission process, increasing the patient's risk for sepsis and death (Baltic, Schlosser, & Bedell, 2002). The purpose of this project was to evaluate the effects of the implementation of a standardized order set on the time interval in initiation of antibiotic therapy for adult patients with cancer and febrile neutropenia who were admitted to the oncology unit of an urban hospital.…”