Intervention boosted early antibiotic development for neutropenic patients

M. Douglas Baker, MD

Worry of infection is a common reason for patients to present to pediatric emergency departments (EDs) and urgent care settings. While the majority of such children are found to be free of bacterial diseases and are safe to manage symptomatically as out-patients, selected groups have higher risk of serious infection that warrants rapid presumptive treatment with antibiotics. Such is the case for children with oncological diseases who are immunocompromised as a result of their primary disease or secondarily due to management thereof. It is generally held that when such children present to EDs for management of fever, they should receive appropriate management, including prompt administration of antibiotics, generally within 60 minutes of arrival. While that target seems reasonable on the surface, the unpredictable nature of EDs sometimes confounds the process, leading to unwanted delays.

Dr. Dianna Volpe and collaborators from Children’s Hospital Boston investigated the causes of delays in administration of antibiotics to immunocompromised oncology patients who presented with fever to their ED. Not surprisingly, they found several failures of clinical processes that were more consistently present than others. Some of those process failures, including pre-identification of prioritized ED triage status (fast pass) and pre-arrival notification of the ED staff by the on-call oncology fellow were thought to have been remedied prior to their study, but were discovered to need reinforcement. Other process issues were newly discovered, and required new remedies. For instance, the newest electronic medical record actually made access to clinical practice guidelines less direct than prior paper-dependent versions. Introduction of newer safety needles resulted in technical difficulties of use by ED nursing staff.

There are a number of take-home messages in this article. It is likely that some of the process difficulties experienced in one ED are present in others. Thus, the authors’ account of their solutions to problems might be applicable in other settings. More importantly, it is important to measure key performance indicators, such as timeliness of antibiotic administration, in order to help assess service excellence and uncover opportunities to improve patient safety. Even in well-working institutions, such opportunities exist.