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Intervention boosted early antibiotic development for neutropenic patients
An intervention that focused on standardizing antibiotic delivery reduced the time it took for neutropenic patients to receive their medications by about 50%, according to a study published online.
Diana Volpe, BSN, RN, and colleagues from the division’s of hematology/oncology and emergency medicine at Children’s Hospital Boston looked at data from a hospital emergency department (ED) that sees about 60,000 patients per year.
The researchers noted that their goal was to deliver antibiotics within 60 minutes of presenting to the hospital. To do this, they set a protocol in place where they re-educating oncology fellows to provide “pre-arrival direction for the ED staff,” as well as establishing a template from telephone referrals “that prompted inclusion of predicted absolute neutrophil count (ANC) either from recent ANC result or chemotherapy.” The oncology staff also encouraged family members to contact them when the patient had a fever.
The researchers noted the time to delivery for these patients went from 99 minutes to 49 minutes for patients who had neutropenia, and from 90 minutes to 81 minutes for patients who may have been neutropenic.
“We believe we were able to rally a large multidisciplinary team to succeed in this effort because of the collective will to provide excellent care for this vulnerable group of children with cancer,” study author Anne M. Stack, MD, told Infectious Diseases in Children.
The researchers noted some study limitations, including the fact that their findings may not be generalizable to other EDs. Regardless, they said, “by applying quality improvement methodology specifically around the challenge of high level communication with an awareness by the multidisciplinary team, we were able to successfully reduce the time to antibiotic administration.”
Disclosure: Ms. Volpe reports no relevant financial disclosures.
Perspective
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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.
