Reducing Time To Antibiotics in Children with Possible Febrile Neutropenia

Abstract

Session B presented Thursday, September 27, 11:30 am-12:30 pm Purpose: Fever Neutropenia is a potentially life-threatening complication of immunocompromising chemotherapy in children with cancer. Prompt initiation of antibiotic therapy may minimize morbidity and mortality associated with this condition and time to antibiotic administration (TTA) under 60 minutes is a benchmark standard held by many institutions. We initiated a quality improvement project designed to ensure greater than 80% of eligible patients in our pediatric emergency department received antibiotics within 60 minutes. Design: This was a quality assurance project and charts are audited monthly to assure the time to antibiotic administration quality measure of less than 60 minutes were met. But, in order to meet our quality goal, three consecutive PDSA cycles were used. Setting: The primary setting of this project is a level 1 trauma teaching hospital with 10 pediatric emergency room beds and an average of 15,000 visits a year. Participants/Subjects: All peds ED Staff RNs, MDs, and pharmacists participated in this project. All patients presenting or being referred with a chief complaint of possible febrile neutropenia were included. Methods: To better understand total time to antibiotic administration (TTA), we analyzed the process into its component parts, most notably time to order antibiotics and time to prepare antibiotics in pharmacy. We employed three consecutive PDSA cycles. The first aimed, through staff education and audit and feedback, to expedite time to placement of the antibiotic order shortly after patient arrival. With modest improvement, the second intervention focused on expediting the preparation and delivery of feedback from pharmacy. The final cycle required collaboration between the emergency department, pharmacy, and informatics to build the capacity to place the antibiotic order prior to patient arrival. Adherence to this process was monitored and was reinforced through individual audit and feedback. Results/Outcomes: Each improvement cycle resulted in progressively decreased mean TTA administration times, from 62.1 minutes in the month prior to the first cycle to 28.6 minutes the month following the final cycle. The percent of patients receiving antibiotics under 60 minutes increased from 78 to 100% during this period. Comparing the pre-intervention and post-intervention years, the overall mean TTA decreased from 63.6 minutes to 46.5 minutes (27%) and the fraction of patients receiving antibiotics in less than 60 minutes increased from 64% to 84%. Improvements were sustained in the maintenance period of the project, with mean TTA administration of 46.6 minutes and 82% of patients receiving antibiotics within our stated goal. Implications: Emergency departments nationally struggle to achieve TTA in < 60 minutes for children with febrile neutropenia. Through a series of improvement cycles, we successfully decreased TTA and increased the percentage patients receiving antibiotics in < 60 minutes. Initiatives such as these should help minimize morbidity and mortality in this vulnerable patient population.