Quality Initiative to Improve time to Antibiotics for Febrile Pediatric Patients with Potential Neutropenia

Abstract

Introduction:In patients who are immunocompromised, fever may indicate a life-threatening infection. Prompt time to antibiotic administration in febrile patients at risk for neutropenia has been identified by national and international panels as a key benchmark of quality care in emergent situations. A quality improvement initiative to improve health care provided in a pediatric emergency department (ED) is described.Methods:A clinical pathway was previously initiated in a pediatric ED with a goal of improving time to antibiotics for febrile neutropenia patients. An agreed upon pathway and order set being initiated. Improvements were seen but not to the desired level. This project involved an improvement cycle that focused on nonvalue added time in the workflow.Results:Percent of patients receiving antibiotics within the goal time of 1 hour increased from 40% to 80% with the intervention. Process measures including arrival to ED bed time, ED bed to antibiotic order time and antibiotic order time to delivery time were followed.Conclusion:Clinical guidelines, order sets and detailed understanding of the actual workflow at the point of care delivery can be instrumental in achieving the goals of reducing time to antibiotics.

Interventions aiming to reduce time to antibiotics (TTA) in patients with fever and neutropenia during chemotherapy for cancer (FN), a systematic review

“…TTA is reported as continuous variable in all but two studies [31,41]. These specific studies only report an increase in percentage of patients treated within 60 min, as it was reported by several other studies, in addition to continuous TTA ( Table 2).…”

“…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%).…”

A Quality Improvement Initiative: Improving Time-to-Antibiotics for Pediatric Oncology Patients with Fever and Suspected Neutropenia

“…Our study included several similar interventions previously described in other TTA QI initiatives, including addressing triage issues with an intervention like a “Fast Pass,” optimizing the Port-a-Cath access procedure through education and providing an additional appropriately sized needle to the patient, and optimizing timeliness of antibiotic ordering and review by ED pharmacist 5 16 17 . These interventions were pivotal to our ultimate success.…”

“…Pediatric patients undergoing chemotherapy treatment for cancer are at risk for severe infections due to chemotherapy-induced neutropenia, a frequent complication of chemotherapy which puts patients in an immunocompromised state, and the presence of central venous access devices (CVADs), which increase the risk for invasive bacterial infections 1-4 . The coincidence of fever and severe neutropenia, commonly called fever and neutropenia (F&N), in child with a CVAD undergoing chemotherapy increases the risk for a life-threatening emergency greater than in patients with non-neutropenic fever (NNF) 5 6 . Given that fever may be the only symptom of an underlying infection at presentation and the absolute neutrophil count (ANC) is typically unknown at the onset of the fever, rapid assessment of and intervention for all children with cancer who have fever and suspected neutropenia is critical.…”

Improving management of fever in neutropenic children with cancer across multiple sites

“…When Clinical Practice Guidelines are adhered to with attention to local processes, workflow and workforce education, they demonstrate improved outcomes, including target time to antibiotic (TTA) administration (Green et al, 2016;Monroe et al, 2018).…”