Sustainability of Change: Evaluating Febrile Neutropenia Process in Pediatric Setting
Jennifer Childress, BSN, RN, CPEN; Kelly Asher, RN; Angela Jones BSN, RN; Amber King, BSN, RN, CPEN; Lisa Maloney, MSN, RN; Kathy Monroe, MD; Stephanie Thompson, RN
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Session A presented Thursday, September 14, 2017
Purpose: Febrile neutropenia is considered an oncologic emergency. It has been shown that decreasing the door-to-antibiotic time for this population positively effects patient outcomes. A pathway was created to improve time to antibiotics (TTA) in a pediatric ED and this project evaluated efforts to sustain this quality improvement initiative.
Design: A quality improvement project including a multi-disciplinary team evaluating data, staff perceptions, and brainstorming innovative ways to sustain change.
Setting: 53-bed level 1 urban pediatric trauma center with approximately 72,000 visits annually.
Participants/Subjects: Immunosuppressed patients of any age, with oncologic/hematologic suppression were included. Transplant patients were excluded. In 2016, we expanded to include any patient followed by Hematology/Oncology for any possible neutropenia.
Methods: Over the course of several years, the Febrile Neutropenia Pathway was updated and monitored. The multi-disciplinary project team included physicians, Oncology providers, emergency department (ED) educators, pharmacy staff, and ED nurses. The pathway was agreed upon by the project team and in late 2011/early 2012 and phase 1 was initiated in the electronic medical record (EMR) using ordersets for central access and obtaining laboratory specimens rapidly to help providers ascertain if patients were neutropenic. Data was monitored quarterly for meeting goals and real time open record review for "just in time training" was used. Data monitored was percent of patient population who received antibiotics in less than 61 minutes from arrival (goal being 90%). In early 2012, phase 2 included agreed upon antibiotic to be used for one time dosing regardless of lab studies. In August 2012, with a move to new facility, compliance percentage fell drastically. After a team Gemba walk in quarter 1, 2013, the non-value adding steps were addressed by organization of supplies into "kits" and pharmacy begain mixing one time doses of Cefepime (phase 3). In quarter 2, 2014, the EMR was changed and the ability to obtain data was greatly hampered; the project team went on hiatus until early 2016. Phase 4 began in 2016 and the project team isolated two metrics for accountability, conducted a literature review, used staff interviews, chart reviews, and Gemba walks to assess the problem. Unit champions began discussing the data points and presenting them to staff in graphical format. This led to improvement, however, staff engagement and understanding remained a low so "scorecards" were posted in staffing areas. Making this project routine for staff and providing accountability to staff has improved our compliance percentages.
Results/Outcomes: Original baseline data shows a compliance rate of 35% which was only improved to 54% meeting the goal at its peak prior to final intervention. Early data at this point shows tremendous improvement (up to 91% with TTA < 61 mins) and both goals were obtained for the first time.
Implications: Sustainablility of change remains a large issue for our institution. Using precepts from the ELIAS Performance Management Framework, we chose to put accountability and routinization at the forefront of our process to affect change and sustain that change over time. This project has areas that are easily adapted for other performance improvement initiatives to ensure long-lasting change.
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