Reducing time to antibiotics in patients with neutropenic fever on a bone marrow transplant unit.

Abstract

310 Background: Timely administration of antibiotics in patients with neutropenic fever (NF) is essential for reducing morbidity and mortality among oncology patients. Due to their immunocompromised state, neutropenic patients are at particularly high risk of developing severe complications from infection. The optimal time to antibiotics (TTA) for patients with NF is unclear, but IDSA/ASCO guidelines recommend a median TTA within one hour of documented fever. This study focused on identifying barriers at a single academic institution to timely antibiotic administration for patients admitted to the inpatient Bone Marrow Transplant (BMT) unit, and implemented new processes to reduce median TTA to less than 60 minutes. Methods: Patients who developed NF during their hospital admission were included in the study. Individuals who were transferred from another facility or presented to the Emergency Department with NF were excluded. Chart reviews were performed to identify root causes for delays in antibiotics (abx). Data was collected for the following time points: time from fever to notification of provider, time from notification to abx order, time from order to release, and time from release to administration. The research team also met with key stakeholders from nursing, pharmacy, advance practice providers, and physicians to better understand the process. Results: Based on the root cause analysis, 4 interventions were implemented: cefepime was stocked in the pyxis (Int 1 – August 2018), NF guidelines were updated (Int 2 – October 2019), Educational videos were created for just in time learning for house staff rotating on the oncology services and an education campaign for the nursing staff (Int 3 – June 2020), a nurse driven protocol to release and administer abx was piloted on the BMT (Int 4 – December 2021). Baseline TTA was 128 minutes. After Int 1, median TTA decreased to 77.2 minutes. Int 2 and Int 3 did not improve median TTA. In October 2020, median TTA had increased to 98 minutes. After Int-4, on the BMT unit, median TTA decreased to 40 minutes. Conclusions: Through iterative changes and process improvement methodology, we were able to improve our median TTA from 128 minutes to 40 minutes. The most impactful changes “simplified the process” to administer abx. Educational initiatives were less impactful, which is consistent with human factor re-engineering science and change management strategies. This improvement initiative spanned over an extended time period largely because of interruptions due to the COVID pandemic. As a result, the project demonstrated that the goal to implementing and sustaining change requires workflow redesign, culture shifts, and engagement by all key stakeholders.