Improving hospital performance in the treatment of febrile neutropenia

Febrile neutropenia (FN) remains a common and dangerous complication of cancer treatment. Guidelines from the Infectious Disease Society of America urge initiating antibiotics within 2 h of presentation. We reviewed our institution's performance to identify areas of needed improvement and to design performance improvement steps.

FN management was deconstructed into discrete tasks. Experienced practitioners estimated appropriate time allowance for each task. Cycle time analysis data on a baseline cohort (baseline group) identified causes and loci of delay. Based on these data, new processes to bypass roadblocks for timely therapy were introduced. Performance monitoring continued as these changes were implemented (the transitional group) and for 20 months thereafter (the post-intervention group).

Sixty-nine episodes of FN were identified. Ten distinct improvement steps were implemented. Median time to antibiotics was reduced from 252 min, to 188 min and 118 min for the baseline, transitional, and post-intervention groups, respectively (p = 0.0002 for the baseline vs. the post-intervention group comparison). Variability was reduced with the inter-quartile range falling from 174 min (baseline) to 65 min (post-intervention). Despite improvement, there were persisting episodes of delays, due to competing priorities from other patients or decisions to postpone infusion of antibiotics until patients had been admitted. Standardized order sets eliminated improper antibiotic choices as a source of error.

Improvements in the management of FN can be accomplished and sustained by the focused study of performance of individual tasks, the design of streamlined processes by practitioners, and the ongoing review of performance with feedback to clinical departments.