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ED interventions reduce time to treatment of febrile neutropenia
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The implementation of an intervention pathway reduced the time to administration of necessary antibiotics in the emergency department among adult patients with cancer experiencing febrile neutropenia, according to results of a prospective study conducted at Cleveland Clinic.
Febrile neutropenia — a serious complication of chemotherapy — is associated with mortality rates as high as 58% in patients with multiple comorbidities. Most practice guidelines recommend the administration of antibiotics within 1 hour of documented fever.
However, since more cancer regimens are received in the outpatient setting, patients experiencing febrile neutropenia are more likely to present in an ED where delays are inherent.
Thus, Mikkael Sekeres, MD, MS, director of the leukemia program and vice-chair for clinical research at the Cleveland Clinic Taussig Cancer Institute, and colleagues sought to define best practice guidelines for this population. Researchers developed this febrile neutropenia pathway to reduce antibiotic delays and to identify value in prompt administration of antibiotics to improve the quality of care for patients.
Mikkael Sekeres
“Fever in the setting of neutropenia in cancer patients is a life-threatening emergency, similar to a heart attack or stroke,” Sekeres told HemOnc Today. “Prompt initiation of antibiotics is critical in minimizing mortality.”
The researchers developed interventions to be used during the study to reduce or eliminate delays to treatment.
“The interventions were not complicated,” Sekeres said. “We standardized our definition of fever; provided patients with wallet-sized cards alerting emergency departments to the potential of this serious condition; worked with our emergency department staff to change the triage level of fever and neutropenia to be equivalent to heart attack or stroke; designed standard febrile neutropenia order sets for our electronic medical record; and relocated the antibiotics used to treat febrile neutropenia to our emergency department.
“Instituting these changes took less than half a year, and the benefits have persisted for years afterwards.”
The primary outcome of the study was time to antibiotic administration and the goal was to have the antibiotics administered within 90 minutes of presentation in the ED. However, after the initiation of this study, Infectious Diseases Society of America and ASCO reduced their time to antibiotic administration goal from 90 minutes to 60 minutes.
Overall, 223 patients who were fast-tracked onto the neutropenia pathway experienced 276 episodes of febrile neutropenia during the 12-month study period. Researchers compared these data with data from 87 patients who experienced 107 episodes in a historical cohort and 101 patients who experienced 114 episodes in a direct admission cohort.
The majority of patients were men (53%) and had hematologic malignancies (56%). The most common cancers in the cohort included leukemia (24%), lymphoma (22%), breast cancer (9%), head and neck cancers (7%) and lung cancers (6%).
The use of the pathway reduced the median time to antibiotic administration from 235 minutes in the historical cohort and 169 minutes in the direct admissions group to 81 minutes in the intervention cohort (P < .001).
Fifty-seven percent of patients in the intervention cohort received antibiotics within the 90-minute goal, and 32% received antibiotics within 60 minutes. Only 1% of the historical cohort and 13% of the direct admission cohort met the 90-minute goal.
Additionally, patients treated within the pathway and a shorter hospital length of stay than the historical cohort (4.3 days vs. 3.3 days); however, this difference did not reach statistical significance.
“We demonstrated that establishing simple interventions decreased the time it took for these patients to receive antibiotics from 4 hours to just over an hour,” Sekeres said. “The febrile neutropenia pathway we instituted decreased the length of hospitalization for patients by approximately one day, thus showing real value to patients.” – by Anthony SanFilippo
For more information:
Mikkael Sekeres, MD, MS, can be reached at Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195; email: ekerem@ccf.org.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Christopher R. Flowers, MD
Reducing the time to antibiotic administration for patients with cancer undergoing chemotherapy who experience fever during a period of neutropenia is a clinically meaningful and important event. Fever during a period of neutropenia is an oncologic emergency that, prolonged, can be associated with worse outcomes when there is a delay in antibiotic administration. This study evaluated the clinical benefit of a febrile neutropenia pathway aimed at reducing delays in antibiotic administration for febrile patients with cancer presenting to the ED. Although the intervention in this study was not associated with a statistically significant decrease in hospital length of stay, other studies have documented length-of-stay benefits for similar types of interventions. This approach did demonstrate a dramatic reduction in the time to antibiotic administration. Thus, this approach and others like it will bring us closer to standards of care outlined in guidelines for patients with cancer who experience fever during a period of neutropenia.
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